Diagnostic assessments and medical evaluations

Page posted: 3/6/24

Diagnostic, medical and/or mental health assessments must always be completed by professionals who are qualified or licensed to conduct them. DHS does not expect 245D-licensed service providers to complete these types of assessments. However, it can be helpful for providers to have a general idea of what information they contain. Licensed practitioners might ask providers to contribute information for these assessments (e.g., collecting data or sharing observations).

Diagnostic assessment (DA)

A DA is a report that documents the clinical and functional face-to-face evaluation of a person’s mental health (refer to MHCP Provider Manual – Mental Health Services: DA). A DA is necessary to determine a person’s eligibility for mental health services. A licensed practitioner will likely conduct a comprehensive DA before a person starts any psychotropic medication. A DA also might be helpful when a person visits a practitioner for the first time, changes practitioners or does not respond to current psychotropic medications.

A DA should include documentation of:

· Nature, severity and impact of behavior difficulties.

· Functional impairment (refer to CDC – Disability and health overview).
Note: Functional impairment is different from a functional behavior assessment as defined in Minn. R. 9544.0040. For more information, refer to Psychotropic Medication Manual – Functional behavior assessment (FBA).

· Subjective distress.

· Strengths and resources.

A DA is just one part of a comprehensive mental health assessment, which also includes a review of a person’s:

· Physical health.

· History of the present illness.

· Previous mental health, physical and medication history.

· Relevant personal and family history.

· Personal strengths and assets.

Medical evaluation

Before using psychotropic medications, a licensed practitioner or other licensed professional must evaluate a person’s physical needs and rule out physical causes of behavior. During a thorough, general medical evaluation, the practitioner typically:

· Obtains the person’s medical history.

· Conducts a comprehensive review of systems.

· Conducts a physical examination.

· Reviews all current medications and treatments.

· Orders lab tests as needed.

The complexity of the assessment depends on the person’s symptoms, diagnoses, relationship between bio-psycho-social variables and quality of life. Observations by those close to the person can be helpful during the evaluation process.

Data on psychiatric symptoms

Licensed practitioners may ask 245D-licensed service providers to collect and report data on psychiatric symptoms. If this occurs, the licensed practitioner should provide a tracking tool to complete this task and indicate a timeframe for the 245D-licensed service provider to collect the data and report it back to the licensed practitioner. Licensed practitioners do not always instruct 245D-licensed service providers to complete these types of assessments. However, doing so can often help determine the effectiveness of the psychotropic medication.

Keep in mind that people with intellectual or developmental disabilities sometimes are referred for psychotropic medications for behaviors that are not psychiatric symptoms (e.g., not following household schedules, refusing to attend work). This type of psychotropic medication use falls under the definition of chemical restraint, as defined under Minn. Stat. §245D.02, subd. 3b. Providers should consult with the licensed practitioner if they have questions about what is or is not a psychiatric symptom. For more information, refer to Psychotropic Medication Manual – Preparing for appointments.

Additional resources

Psychotropic Medication Manual
Psychotropic Medication Manual – Appointments